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Childhood Psychiatric Disorders

Teketel Tegegn
MD, Neuropsychiatrist .

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DSM 5 ICD 10
Neurodevelopmental Disorders Mental retardation
• Intellectual Disabilities Pervasive developmental disorders
• Communication Disorders • Childhood autism; Atypical autism;
• Autism Spectrum Disorder Other childhood disintegrative disorder
• ADHD +++
• Specific Learning Disorder Behavioural and emotional disorders
with onset in childhood and
• Motor Disorders adolescence
• Other • Hyperkinetic disorders
Elimination Disorders • Conduct disorders
• Enuresis, Encopresis • Unsocialized/Socialized conduct
Disruptive, impulse-Control, and disorder
Conduct Disorders • Oppositional defiant disorder
• Conduct Disorder Other behavioural and emotional
• Oppositional Defiant Disorder disorders ….
• Intermittent Explosive Disorder • Nonorganic enuresis, encopresis
• Antisocial Personality Disorder • Feeding disorder of infancy and
Depressive disorder- Disruptive childhood; Pica +++
Mood Dysregulation Disorder

•Separation anxiety disorder


•Selective mutism
•Reactive attachment disorder MCM Psych 2017 2
•Disinhibited social engagement disorder
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1. Intellectual Disability
2. Autism spectrum disorder
3. ADHD- Attention Deficit Hyperactivity
Disorder
4. Disruptive Mood Dysregulation Disorder
5. Disruptive behavior disorder
6. Elimination disorder- Enuresis

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Type of Prevalence
disorder
Intellectual Overall prevalence of ~1%; vary by age
disability
Autism spectrum ~1% of the population
disorder
ADHD ~ 5% of children and ~ 2.5% of adults
Oppositional defiant disorder -average
prevalence estimate of around 3.3%
Disruptive Intermittent explosive disorder - one-year
behavior prevalence - in USA ~ 2.7%
disorder
Conduct disorder - One-year population
prevalence - from 2% to > 10%, with a median
of 4%.
Disruptive mood overall 6-month to 1-year period-prevalence
dysregulation among children and adolescents probably -
2%-5%
Enuresis 5%-10% among 5-year-olds,
3%-5% among 10-year-olds,
~ 1% among individuals 15 years or older.

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1. Intellectual Disability (Intellectual
Developmental Disorder) - Mental
retardation

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• Most typically manifest early in development

• Characterized by developmental deficits that


produce impairments of
– Personal functioning
– Social functioning
– Academic functioning
– Occupational functioning

• Frequently co-occur
– Individuals with autism spectrum disorder often
have intellectual disability
– Children with ADHD will have a specific learning
disorder
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DSM-5 criteria
Onset during the developmental period that
includes both intellectual and adaptive
functioning - Deficits in conceptual, social, and
practical domains.
The following three criteria must be met:

A. Deficits in intellectual functions, such as


– reasoning, problem solving
– planning
– abstract thinking, judgment
– academic learning
– learning from experience, or instruction
confirmed by both clinical assessment /intelligence
testing
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B. Deficits in adaptive functioning - result in failure


to meet developmental and sociocultural
standards for personal independence and social
responsibility.
Limited functioning in one or more activities of
daily life, such as
– Communication
– Social participation
– Independent living
across multiple environments, such as
– Home, school, work, Community

C. Onset of intellectual and adaptive deficits during


the developmental period

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Adaptive functioning- adaptive reasoning in three


domains

a. The conceptual (academic) domain -


competence in
• Memory
• Language
• Reading
• Writing
• Math reasoning, etc.

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b. The social domain


• Awareness of others’ thoughts, feelings,
experiences, empathy
• Interpersonal communication skills
• Friendship abilities
• Social judgment
c. The practical domain - learning and self-
management across life settings
– Personal care
– Job responsibilities
– Money management
– Recreation
– School and work task organization

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Mental retardation
IQ % Socio Academi Residence Economic
economic c level
class
Mild 50-55 85 low 6th-grade community Hold jobs
to educable
~70
Moderate 35-40 10 Less low 2nd-grade sheltered Manage pocket
to trainable- money-can
50-55 self care hold minor job
Severe 20-25 4 No skew Below 1st highly can use coin
to grade structured machines; can
35-40 (simple and closely take notes to
skills) supervised stores when
shopping.
Profound Below 1 No skew - highly Dependent on
20-25 structured others
and closely
supervised

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Etiology

 Problems before child is born – malnutrition,


alcohol, iodine deficiency, infections
 Problems during birth –prolonged labor
 Problems in the first year of life –infections of
brain, prolonged jaundice, severe malnutrition,
convulsions
 Poor care- lack of stimulation, child abuse,
emotional neglect
 Genetic condition- fragile X syndrome, Prader-
Willi syndrome, and Down syndrome

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Co-morbid neuropsychiatric conditions

Many with mental retardation have co-morbid


mental disorders
• Disruptive and conduct-disorder behaviors
• Mood disorders
• Psychosis - Schizophrenia
• Attention-deficit/hyperactivity disorder
• Seizure

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Treatment

 Treat comorbid psychiatric disorders

 Treat metabolic and endocrine disorders

 Psychosocial support
Minimize the sequelae or consequent disabilities
o Training in
o adaptive skills
o communication skill
o social skills
o vocation
No cure, only improve the quality of life
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Pharmacotherapy – of comorbidity

• Methylphenidate –ADHD
• Risperidone–ADHD; aggression and self-injurious
behavior
• Lithium - aggression and self-injurious behavior
• Carbamazepine and valproic acid - aggressive
behavior, seizure
• Antidepressants (SSRI, TCA)- depression,
– SSRI’s for pervasive developmental disorder,
OCD
• Antipsychotic medications: repetitive self-
stimulatory behaviors, explosive rages
• Beta-blockers- propranolol: explosive rages
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2. Autism Spectrum Disorder

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DSM-IV TR diagnosis of

• Autistic disorder
• Asperger’s disorder
• Childhood disintegrative disorder
• Rett's disorder
• Pervasive developmental disorder not otherwise
specified

should be given the diagnosis of Autism Spectrum


Disorder (DSM 5)

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DSM 5 criteria

A. Persistent deficits in social communication and


social interaction across multiple contexts

B. Restricted, repetitive patterns of behaviour,


interests, or activities

C. Symptoms must be present in the early


developmental period

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a. Social communication and social interaction


1. Deficits in social-emotional reciprocity
• failure of normal back-and-forth conversation
• reduced sharing of interests, emotions, or
affect
• failure to initiate or respond to social
interactions

2. Poorly integrated verbal and nonverbal


communication
• abnormalities in eye contact and body
language
• deficits in understanding and use of gestures
• total lack of facial expressions and nonverbal
communication
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3. Deficits in developing, maintaining, and


understanding relationships

• difficulties adjusting behaviour to suit various


social contexts
• difficulties in sharing imaginative play or in
making friends
• absence of interest in peers

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b. Restricted, repetitive patterns of behavior


1. Stereotyped or repetitive motor movements, use
of objects, or speech
– lining up toys or flipping objects,
– echolalia,
– idiosyncratic phrases

2. Insistence on sameness or inflexible adherence to


routines
• Ritualized patterns of verbal or nonverbal
behaviour
– rigid thinking patterns, greeting rituals
– need to take same route or eat same food every
day
– extreme distress at small changes,
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3. Highly restricted, fixated interests that are


abnormal in intensity or focus
– strong attachment to or preoccupation with
unusual objects
– excessively circumscribed or perseverative
interests

4. Hyper- or hyporeactivity to sensory input or


unusual interest in sensory aspects of the
environment
– apparent indifference to pain/temperature,
– adverse response to specific sounds or textures
– excessive smelling or touching of objects
– visual fascination with lights or movement
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D. Clinically significant impairment in social,


occupational, or other important areas of
current functioning.

E. Not better explained by intellectual disability


(intellectual developmental disorder) or global
developmental delay.

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Associated features

• Motor deficits -odd gait, clumsiness, and


other abnormal motor signs (e.g., walking
on tiptoes).
• Self injury (e.g., head banging, biting the
wrist)
• Disruptive/challenging behaviours
• Prone to anxiety and depression.
• Catatonic-like motor behaviour (slowing and
"freezing" mid-action)

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Etiology
Multifactorial disorders
A. Genetics
B. Environmental Pollutants and Toxins
C. Vaccines, Viruses and Impaired Immune Systems
D. Nutrition, Food Sensitivities and Digestive
Disorders
E. Additional in utero Factors

Risk and Prognostic Factors


• Presence or absence of associated intellectual
disability
• Presence or absence of associated language
impairment
• Additional mental health problems, and epilepsy
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Treatment
A.Behavioral programs
• Careful training of parents in the concepts and
skills of behavior modification
• Structural classroom training – in combination with
behavioral methods
• “Facilitated communication” technique
B. Pharmacotherapy
To control behavioral/additional symptoms
1. Atypical antipsychotics
2. Lithium
3. SSRI’s
4. Methylphenidate
5. Anticonvulsants
C. Dietary
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3. ADHD- Attention Deficit Hyperactivity
Disorder

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• Persistent pattern of
– inattention
– hyperactivity
– impulsive behavior

• Most common psychiatric disorder among school-


age children

• Interferes with functioning or development

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ADHD-Diagnostic criteria(DSM 5)
 Minimum of six symptoms from each group
o Inattention
o Hyperactivity-impulsivity
 Several symptoms were present prior to age 12
years
 A minimum duration of 6 months
 Persistent symptoms
 Impairment in two or more settings
 Three major components
1. Inattention
2. Hyperactivity
3. Impulsivity

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1. Inattention

• fails to give close attention to details or makes


careless
• mistakes in schoolwork, work, or other activities
• difficulty sustaining attention in tasks or play activities
• does not seem to listen when spoken to directly
• does not follow through on instructions and fails to
finish schoolwork, chores, or duties in the workplace
• has difficulty organizing tasks and activities
• avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort/such as schoolwork or
homework
• loses things necessary for tasks or activities/e.g. toys,
school assignments, pencils, books, or tools
• easily distracted by extraneous stimuli.
• forgetful in daily activities
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2. Hyperactivity

 fidgets with hands or feet or squirms in seat


 leaves seat in classroom or in other situations in
which remaining seated is expected
 runs about or climbs excessively in situations in
which it is inappropriate
 has difficulty playing or engaging in leisure
activities quietly
 "on the go" or often acts as if "driven by a motor"
 talks excessively

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3. Impulsivity

 blurts out answers before questions have


been completed
 has difficulty awaiting turn
 often interrupts or intrudes on others (e.g.,
butts into conversations or games)

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Etiology

 Not known

 Gross structural damage in the CNS not present

 Lack of neurophysiological & neurochemical base


o EEG abnormality?
o decreased blood flow on the frontal lobe?
o ? change in noradrenergic system (locus
ceruleus & peripheral sympathetic system)

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Possible contributing factors

 Prenatal toxic exposures, Prematurity, prenatal


mechanical insult to the fetal CNS

 Genetic factors –twin studies, family history

 Brain damage –infection, inflammation &


trauma

 Psychological factors –prolonged emotional


deprivation, stressful psychic events, disruption
of family equilibrium

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Treatment

Pharmacotherapy
 Psychostimulants
o Amphetamines & amphetamine like substances
o Methylphenidate

 Other drugs
o Bupropion –with commorbid depression
o Clonidine –tic disorder
o Tricyclics –despiramine (?safety concern)
o Antipsychotics
o Modafinil –used for narcolepsy
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Behavioral therapy

Advice to the parents


• When the child behaves badly – “time out”,
ignore the behavior or leave the room
• Give praise or reward when child behaves
• Do not give too many commands
• Be specific on what you want the child to do
• Regular sport or physical activity
• Establish regular routine for the child
• Reduce stimulation - avoid taking him to
crowded places like markets, weddings

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Advice to the teacher

• Student’s seat near the teachers desk- more


attention, less distraction
– Avoid distraction- not near window or door

• When giving instruction


– Look at the student
– Clear and concise instruction
– Avoid multiple compounds – break tasks into
small components
– Ask the child to repeat the instruction

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4. Disruptive Mood Dysregulation
Disorder

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Disruptive Mood Dysregulation Disorder


A. Severe recurrent temper outbursts
manifested verbally (e.g., verbal rages) and/or
behaviorally (e.g., physical aggression toward
people or property) that are grossly out of
proportion in intensity or duration to the situation
or provocation.
B. The temper outbursts are inconsistent with
developmental level.
C. The temper outbursts occur, on average, three or
more times per week.
D. The mood between temper outbursts is
persistently irritable or angry most of the day,
nearly every day, and is observable by others
(e.g., parents, teachers, peers).
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E. Criteria A-D have been present for 12 or more


months. Throughout that time, the individual has
not had a period lasting 3 or more consecutive
months without all of the symptoms in Criteria A-D.

F. Criteria A and D are present in at least two of three


settings (i.e., at home, at school, with peers)
and are severe in at least one of these.

G. The diagnosis should not be made for the first time


before age 6 years or after age 18 years

H. By history or observation, the age at onset of


Criteria A-E is before 10 years.
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5. Disruptive Behaviour Disorders

a. Oppositional Defiant Disorder


b. Intermittent Explosive Disorder
c. Conduct Disorders

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a. Oppositional Defiant Disorder

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At least 6 months as evidenced by at least four


symptoms
Angry/Irritable Mood
1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.
Argumentative/Defiant Behaviour
4. Often argues with authority figures or, for
children and adolescents, with adults.
5. Often actively defies or refuses to comply with
requests from authority figures or with rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or
misbehavior.
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Vindictiveness
8. Has been spiteful or vindictive(mean, malicious,
unkind) at least twice within the past 6 months.

The behaviours do not occur exclusively during the


course of a psychotic, substance use, depressive,
or bipolar disorder.

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b. Intermittent Explosive Disorder

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Intermittent Explosive Disorder

A. Recurrent behavioral outbursts representing a


failure to control aggressive impulses
1. Verbal aggression (e.g., temper tantrums,
tirades, verbal arguments or fights) or physical
aggression toward property, animals, or other
individuals, occurring twice weekly, on average,
for a period of 3 months.

2. Three behavioral outbursts involving damage or


destruction of property and/or physical assault
involving physical injury against animals or other
individuals occurring within a 12-month period.

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B. Aggressiveness /recurrent outbursts - grossly out


of proportion to the provocation /stressor

C. Not premeditated and are not committed to


achieve some tangible objective (e.g., money,
power, intimidation).

D. Marked distress in the individual or impairment in


occupational or interpersonal functioning, or are
associated with financial or legal consequences.

E. Chronological age is at least 6 years (or


equivalent developmental level).

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C. Conduct Disorders

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At least 3 of the following 15 criteria in the past 12


months from any of the categories - at least one
criterion present in the past 6 months:
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others.
2. Often initiates physical fights.
3. Has used a weapon that can cause serious
physical harm to others (e.g., a bat, brick, broken
bottle, knife, gun).
4. Has been physically cruel to people.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim (e.g.,
mugging, purse snatching, extortion, armed
robbery).
7. Has forced someone into sexual activity.
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Destruction of Property
8. Has deliberately engaged in fire setting with the
intention of causing serious damage.
9. Has deliberately destroyed others’ property
(other than by fire setting).

Deceitfulness or Theft
10. Has broken into someone else’s house, building,
or car.
11. Often lies to obtain goods or favours or to avoid
obligations (i.e., “cons” others).
12. Has stolen items of nontrivial value without
confronting a victim (e.g., shoplifting, but without
breaking and entering: forgery).

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Serious Violations of Rules


13. Often stays out at night despite parental
prohibitions, beginning before age 13 years.
14. Has run away from home overnight at least twice
while living in the parental or parental surrogate
home, or once without returning for a lengthy
period.
15. Is often truant from school, beginning before age
13 years.

B. Clinically significant impairment in social,


academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria
are not met for antisocial personality

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Etiology
No single factor - combination of biological,
environmental, and psychological factors

A- Environmental
1. Parental Factors-Harsh, punitive parenting -
severe physical and verbal aggression
– Chaotic home conditions, Divorce
– Sociopathy, alcohol dependence, and substance
abuse in the parents
2. Socioeconomic - growing up in urban
environments; Unemployed parents, etc.

3. Child Abuse and Maltreatment


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B. Biological
– Neurobiological Factors - Neurotransmitters-
NE, serotonine,
– EEG abnormalities

C. Psychological
– Unresolved conflicts as fueling aggressive
behaviors towards authority figures(oppositional
defiant disorder)
– Reinforced, learned behavior; poor modeling of
impulse control

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Treatment for Disruptive Behaviour Disorders

Psychological
o Behavioral
o Family therapy

Pharmacological
• Drugs rarely required
– For the most severe cases
– For impulse control, very aggressive behaviour
• Anticonvulsants such as valproate or
carbamazepine,
• Antipsychotics – Risperdal, haloperidol
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6. Enuresis
(Elimination Disorder)

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DSM 5 criteria
A. Enuresis is the repeated voiding of urine into a
child's clothes or bed – whether involuntary or
intentional

B. Twice weekly for a period of at least 3 months


– Cause distress and impairment in functioning

C. Chronological age is at least 5 years (or


equivalent developmental level)

D. Not caused by a medical condition.

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Why children wet their bed?

• Primary enuresis – never been dry


 Delayed or lax toilet training
 Delay in development - not necessarily mental
retardation
 Genetic- familial
• Secondary enuresis - Environmental factors,
parental conflict, arrival of new baby, etc.

Have higher risk for


– developmental and behavioral disturbances
compared with children without enuresis

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Evaluation

Excluding medical illnesses

• History - a voiding diary


• Physical examination
• Laboratory tests- Urinalysis
• Other- urological, imaging

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Treatment

Behavioral
• Pass urine in the toilet just before bedtime

• Give praise when the child does not wet

• Wake the child in the middle of the night to make


him go to toilet

• Retention control training


– Encourage the child to “hold’ his urine longer at
the day time
– Stop urinating before finishing, hold few seconds
and start urinating

• Bell - Buzzer alarms


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Medications

• Desmopressin

• Tricyclic antidepressants
– decrease the amount of time spent in REM
sleep
– stimulate vasopressin secretion
– relax the detrusor muscle
Imipramine, Amitryptyline

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